Residency

Experience and Qualifications

In the spaces below give a complete and consecutive work history covering the last 10-years of employment. Show all periods of unemployment and explain reasons for leaving each job. Begin with your present employer and work backwards down the page. Be sure to account for each month of your work experience and explain all periods of unemployment along with dates of unemployment.

Traffic Convictions and Forfeitures for the past (5) Years (Other Than Parking)

Date

Location

Offense

Penalty

Accident Record for the Past Five (5) Years

Date

Type of Accident: Head On, Backing, ETC.

Fatalities

Injuries

Section 382.413 of the Federal Motor Carrier Safety Regulations states: “An employer shall obtain, pursuant to a driver’s consent, information on the driver’s alcohol tests with a concentration result of 0.04 or greater, positive controlled substance test results, and refusals to be tested, within the preceding three-years, which are maintained by the driver’s previous employers under Section 382.401(b)(1)(i) through (iii).”
I hereby authorize and give my consent to all former employers to release such information, as specified in Section 382.413(b) of the Federal Motor Carrier Safety Regulations, to this Motor Carrier.
Section 382.405(h) of the Federal Motor Carrier Safety Regulations states: “An employer shall release information regarding a driver’s records as directed by the specific, written consent of the driver authorizing release of the information to an identified person.”
I AUTHORIZE WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THIS MOTOR CARRIER TO FURNISH THE ABOVE MENTIONED INFORMATION.

Criminal Background

Have you ever been denied a license, permit or privilege to operate a motor vehicle?*

Yes

No

Has any license, permit or privilege been suspended or revoked?*

Yes

No

Have you ever been convicted for driving while intoxicated?*

Yes

No

Has any license, permit or privilege been suspended or revoked?*

Yes

No

Have you ever been convicted for possession, sale or use of a narcotic drug?*

Yes

No

Have you ever been arrested or convicted of a crime?*

Yes

No

If answer to any questions above is yes, state circumstances and dates:

APPLICANT CERTIFICATION STATEMENT

DOT Mandated Drug and Alcohol Testing Program*

Yes, I have information to report on my drug and alcohol history

No, I do not have information to report on any violations of the DOT Drug and Alcohol testing regulations

If while in a DOT mandated drug and alcohol testing program for any employer who had to meet the requirements for any DOT operating agency (FMCSA, FAA, FTA, Coast Guard, RSPA, or FRA) it was determined that you violated drug and alcohol regulations within the prior two-years from the date of application, or if you have not completed the return-to-duty process for any prior violation, you need to complete the following two sections.

I was deemed to have violated one or more of the following DOT prohibitions

I had a verified positive drug test for a prior employer or as a pre-employment test

I had an a alcohol test with an alcohol concentration of 0.04 or greater for a prior employer

I refused to be tested (includes submitting a substituted or adulterated specimen)

I performed a safety-sensitive function within four hours after using alcohol

I was involved in an accident that required post-accident testing and I used alcohol prior to being tested

I used controlled substances while performing a safety-sensitive function

I was deemed to have violated a drug or alcohol regulation under any mandated program which I have not listed above

I have completed the return to duty requirements

Yes

No

Below I have indicated where the violation took place either as an applicant or employee of said company:

Employers Name

Employers Designated Employer Representative

Employers Address

Employers Phone Number

Substance Abuse Professional information

Certification: I CERTIFY THAT ALL INFORMATION IS COMPLETE AND ACCURATE. I UNDERSTAND THAT FAILURE TO ACCURATELY REPORT INFORMATION MAY RESULT IN MY NOT BEING LEASED OR TERMINATION OF MY LEASE IF I AM LEASED ON.

Signature*

I hereby authorize this company the right to make a thorough investigation of my past employment, education and activities and I release from all persons, companies and corporations supplying information. I indemnify this company against any liability that may result from making such investigations. I understand that any false answer or statement or implication made by me in this application or other required document shall be considered sufficient cause for denial of leasing or discharge. Additionally, I understand that nothing contained in this application, the granting of an interview, or being invited to take a physical, be road tested or allowed to attend training class is intended to create a lease contract between this company and myself for either leasing or for the providing of any benefit. No promises regarding leasing have been made to me and I understand that no such promise or guarantee is binding upon this company unless made in writing. If a leasing relationship is established, I understand that I have the right to terminate my relationship subject to the terms of my lease and that the company has the same right. My signature below certifies that I completed this release, and that all entries on it and information in it are true, correct and complete. In connection with my application with you I understand that an investigative consumer report is being requested from DAC Services, or another provider, which will include information as to my character, work habits, performance and experience, along with reasons for termination of past employment from the previous employers. Further I understand that you will be requesting information regarding my driving record and or information from various federal, state and other agencies which maintain records concerning traffic offenses, accidents, etc. as well as information from DAC or other sources concerning: (1) previous driving record requests made by others from such state agencies; (2) state provided driving records; (3) claims involving me in the files of insurance companies; (4) employment histories. I have a right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I hereby consent to your obtaining the above information from DAC or other companies or sources and agree that such information which these sources has or obtains, and my employment history with you, if leased will be supplied to DAC or other companies that subscribe to their/these services. If you desire, you can review any of this information we receive when processing your application. INVESTIGATIONS AND INQUIRIES By my signature below, I authorize this company to conduct an investigation as required by 391.23. The release of information as required by Federal Motor Carrier Safety regulations is granted to the carrier named above. I hereby grant you the authority to release the following information: General driver identification and employment verification information including dates of employment, duties and type of equipment driven. Accident information for all DOT recordable accidents as defined by 390.5 of the regulations, and information regarding any additional accidents (DOT or Non-DOT) that you wish to provide to the prospective employers. DRUG AND ALCOHOL TEST RESULTS Section 382.413 of the Federal Motor Carrier Safety Regulations states: “An employer shall obtain, pursuant to a driver’s consent, information on the driver’s alcohol tests with a concentration result of 0.04 or greater, positive controlled substance test results, and refusals to be tested, within the preceding three-years, which are maintained by the driver’s previous employers under Section 382.401(b)(1)(i) through (iii), Section 40 of the Federal Motor Carrier Safety Regulations” I hereby authorize and give my consent to all former employers to release such information, as specified in Section 382.413(b) of the Federal Motor Carrier Safety Regulations to this Company. Section 382.405(h) of the Federal Motor Carrier Safety Regulations states: “An employer shall release information regarding a driver’s record as directed by the specific, written consent of the driver authorizing the release of the information to an identified person.” I AUTHORIZE WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THIS COMPANY TO FURNISH THE ABOVE MENTIONED INFORMATION.